LPI, Iridoplasty, or ECP for Chronic Angle

COVER STORY
ONLINE SURVEY
LPI, Iridoplasty, or ECP for
Chronic Angle-Closure
Glaucoma?
Laser treatment remains a mainstay of management.
BY SHAN LIN, MD
L
aser treatment can play a key role in the management of primary angle-closure glaucoma (PACG). The
choice of laser therapy usually depends on the mechanism responsible for the anatomic configuration predisposing a patient to PACG. This review summarizes the
indications for performing a laser peripheral iridotomy (LPI),
iridoplasty, and endoscopic cyclophotocoagulation (ECP).
trabecular meshwork may not be able to accommodate the
inflammation induced by the LPI, and the IOP may spike as
a result.
Recent studies have suggested that the LPI should be in
the horizontal position to help avoid postoperative visual
disturbances such as photopsias.3 Also, creating a sufficiently
large iridotomy can be important for ensuring opening
of the angle.4 Figure 1 presents a patient whose angle was
occludable even in the presence of a patent LPI. After
enlargement of the LPI, it is clear that the angle has opened
substantially (Figure 2).
LASER PERIPHERAL IRIDOTOMY
LPI is the primary laser surgery for the treatment of
PACG. Traditionally, a pupillary block mechanism has been
thought to cause approximately 90% of cases of PACG, but
recent data have suggested that a large proportion is related IRIDOPLASTY
to plateau iris anatomy.1,2 LPI is still considered as a first-line
The use of argon laser iridoplasty for angle closure is contreatment in these situations, however, because there is usu- troversial. There is a paucity of prospective research evaluatally a component of pupillary block even when a plateau
ing the safety and efficacy of this procedure. A recent study
iris exists. Also, a plateau iris cannot truly be diagnosed until from Beijing compared LPI alone versus LPI plus argon laser
after an LPI is performed.
iridoplasty for the treatment of primary angle closure and
The indication for performing an LPI is an occludable
PACG.5 One year postoperatively, there were no significant
angle for 180º (two quadrants) or more on gonioscopy. An
differences between the two groups in terms of IOP reducangle is occludable if the examiner can observe only the
tion, corneal endothelial cell counts, or overall complication
anterior trabecular meshwork or less
A
B
without indentation. Gonioscopy
should be performed under dark
conditions to prevent miosis of the
pupil, and the height and intensity of
the slit-lamp beam should be minimized so that no light enters the
pupil. If necessary, the examiner can
slightly tilt the goniolens in order to
peer over a high lens vault.
LPI should not be performed
on eyes with more than 180º of
Figure. 1. A 38-year-old man with microphthalmia has persistent occludable angles
peripheral anterior synechiae (PAS). after LPI. At the slit lamp, the peripheral anterior chamber is shallow (A) but deepens
The reason is that the remaining
after the LPI is enlarged (B).
40 GLAUCOMA TODAY MARCH/APRIL 2015
COVER STORY
rates. There was a possible prevention of 1 clock hour of
PAS in the combined laser group compared to the LPI-only
group. Ritch et al have shown an improvement in the angle
architecture after iridoplasty.6 This procedure may be particularly helpful in cases of plateau iris with a persistent narrow angle despite LPI.
A prospective study of the long-term effects of iridoplasty
versus observation in post-LPI eyes that are still occludable
would help guide clinicians. Until iridoplasty is clearly demonstrated to be of clinical benefit to patients with occludable angles after LPI, I will avoid using this procedure.
ENDOSCOPIC CYCLOPHOTOCOAGULATION
Endoscopic cyclophotocoagulation (ECP) may have
particular advantages in the treatment of PACG aside from
the IOP-lowering effects of ciliary body destruction and suppressed aqueous production. Some surgeons have advocated a form of ECP, known as endocycloplasty, to improve the
angle architecture, thus enhancing aqueous outflow.7 With
endocycloplasty, laser energy is directed at the posterior
portion of the ciliary process to cause shrinkage and concurrent retraction of the process and iris root posteriorly.
Endocycloplasty has been used primarily as an adjunct with
phacoemulsification cataract extraction and may be indicated for plateau iris if ciliary processes are directed anteriorly.
When most of the angle is closed by PAS, however, it may
not be prudent to use ECP, because there is usually a substantial amount of inflammatory debris that may have difficulty exiting the anterior chamber and cause an IOP spike.
LENS REMOVAL: THE ULTIMATE THERAPY?
Ultimately, the most effective treatment for patients
with ACG—and perhaps even a cure in many cases—is to
remove the lens, whether cataractous or clear. Studies from
Hong Kong have demonstrated a significant reduction in
IOP and the number of glaucoma medications in PACG
WEIGH IN ON
THIS TOPIC NOW!
Survey link: https://www.surveymonkey.com/s/
GlaucomaToday29
If the angle can still be occluded after laser
peripheral iridotomy, do you consider performing
argon laser iridoplasty?
Yes
No
A
B
Figure 2. Shown here is the same patient described in Figure 1.
Anterior segment optical coherence tomography prior to
enlargement of the LPI (A) and after enlargement (B). The
angle has widened significantly.
cases.8,9 Clear lens extraction has also been shown to be
effective in treating PACG.10
CONCLUSION
Laser treatment has been a mainstay for PACG, and LPI
remains the first-line approach to most cases. If the angle
remains occludable and/or if the IOP is still uncontrolled,
however, iridoplasty or ECP may be a reasonable adjunctive
procedure to help improve angle anatomy. n
Shan Lin, MD, is a professor of clinical ophthalmology and director of the Glaucoma Service,
Department of Ophthalmology, University of
California, San Francisco. Dr. Lin may be reached
at (415) 514-0952; lins@vision.ucsf.edu.
1. Kumar G, Bali SJ, Panda A, et al Prevalence of plateau iris configuration in primary angle closure glaucoma using
ultrasound biomicroscopy in the Indian population. Indian J Ophthalmol. 2012;60(3):175-178.
2. He M, Friedman DS, Ge J, et al. Laser peripheral iridotomy in eyes with narrow drainage angles: ultrasound biomicroscopy
outcomes. The Liwan Eye Study. Ophthalmology. 2007;114(8):1513-1519.
3. Vera V, Naqi A, Belovay GW, et al. Dysphotopsia after temporal versus superior laser peripheral iridotomy: a prospective
randomized paired eye trial. Am J Ophthalmol. 2014;157(5):929-935.
4. Bochmann F, Johnson Z, Atta HR, Azuara-Blanco A. Increasing the size of the a small peripheral iridotomy widens the
anterior chamber angle: an ultrasound biomicroscopy study. Klin Monbl Augenheilkd. 2008;225(5):349-352.
5. Sun X, Liang YB, Wang NL, et al. Laser peripheral iridotomy with and without iridoplasty for primary angle-closure
glaucoma: 1-year results of a randomized pilot study. Am J Ophthalmol. 2010;150(1):68-73.
6. Ritch R, Tham CC, Lam DS. Argon laser peripheral iridoplasty (ALPI): an update. Surv Ophthalmol. 2007;52(3):279-288.
7. Tam DY. Treating glaucoma: in defense of ECP. Review of Ophthalmology. March 2013. http://bit.ly/1xd1Ls2.
8. Tham CC, Kwong YY, Leung DY, et al. Phacoemulsification versus combined phacotrabeculectomy in medically controlled
chronic angle closure glaucoma with cataract. Ophthalmology. 2008;115(12):2167-2173.e2.
9. Tham CC, Kwong YY, Leung DY, et al. Phacoemulsification versus combined phacotrabeculectomy in medically
uncontrolled chronic angle closure glaucoma with cataracts. Ophthalmology. 2009;116(4):725-731.e1-3.
10. Barbosa DT, Levinson AL, Lin SC. Clear lens extraction in angle-closure glaucoma patients. Int J Ophthalmol.
2013;6(3):406-408.
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